Forms & Articles

Insurance Forms

Patients who require treatment with antiacid medications called proton pump inhibitors (PPIs) may require authorization from their insurance companies for the medication. The forms used by several insurance companies are shown below. Please print, fill out, and return this form to us when preauthorization is required. This will ensure timely delivery of your medications.

Blue Cross Authorization Form 
Aetna Authorization Form 
HealthNet Authorization Form 


Some patients require more than once daily dosing of PPIs in order to control their symptoms. The Academy of Otolaryngology/Head and Neck Surgery recognizes this important fact and has released a position statement to that effect. If your insurance company is reluctant to provide you with the medication you require, please send a copy of this article to your insurance representative, which supports the role of multiple daily doses of PPIs in certain conditions.

Position statement of the Committee on Speech, Voice and Swallowing Disorders of the American Academy of Otolaryngology 

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